12/08/15 rvsd; 06/25/16 rvsd; 12/2/2016 rvsd; 07/03/2017 rvsd

Date: ____________________ Healthy Minds Healthy Body Institute

Registration Form 2018 Present Child's Name ______________________________ BD _________________ Age ______ Grade ______ M F Parent(s) Name_______________________ Address__________________________________________ Street City zip Best Phone ( )__________________ 2nd Best Phone (___) ________________ Continuing Student? ___Yes EMAIL __________________________@_____________________._____________ Diagnosis (if any) ________________________________________________________________________________ We are GREEN and use EMAIL for general information!! Your email here:____________________@_________._____ Check the Program & Age group you wish to enroll your child into for the session. Please note that the schedule (class, time, and day) is subject to change depending upon enrollment. Classes with fewer than 3 students are subject to cancellation for the Session. Additional classes will be added based upon interest & size of class. If you have questions regarding availability of any programs not listed or additional days and time call (925) 484-0074. NOTE: F = Fall Session S = Spring Session (Summer Schedule out in April ‘18) Junior PALS Social Skills Training – Preschool & Kindergarten Age Group Day of Week Sessions Time Program* ______ 3 - 4 Monday F, S 2:30 – 3:20 Preschool- Me and My Emotions ______ 4 - 6 Tuesday F, S 2:15 – 3:05 Jpals – Life Skills ______ 5 - 6 Monday F, S 3:30 – 4:20 Kindergarten/1 & 2 grade PALS Social Prob-Slvg, Self- Esteem, Incr Flex U, Zones of Regulation Program (based on recommendation at intake) Age Group Day of Week Sessions Time Program ______ 6 - 8 Tuesday F, S 3:30 – 4:20 Incredible Flexible You –GST ______ 6 – 8 Tuesday F, S 4:00 – 4:50 Incredible Flexible You ______ 7 - 9 Wednesday F, S 4:30 – 5:20 PALS1, 2, or 3 -GST ______ 7 - 9 Wednesday F, S 5:15 – 6:05 Zones ______ 8 - 10 Wednesday F, S 6:15 – 7:05 Superflex ______ 8 – 10 Tuesday F, S 6:40 – 7:30 Zones ______ 10 -13 Thursday F, S 5:00 – 5:50 Social Thinking Girls’ Club/Boys Club/Pre-Teen Self-Enhancement/ Positive Interaction Groups Age Day of Week Sessions Time Program ______ 9 – 11 Monday F, S 4:30 – 5:20 Spotlight Series- Elementary ______ 12 – 14 Thursday F, S 5:00 – 5:50 Spotlight on -Social Skills _____ 15 – 18 Thursday F, S 6:00 – 6:50 Spotlght on - Communication ______ 12 + Tuesday F, S 5:00 – 5:50 Boys/Girls Club

Have No Fear - Anxiety Group / Emotional Regulation (for Parents and for Children) Age Group Day of Week Sessions Time Program ______ 7 - 8 Thursday F, S 4:00 – 4:50 ______ 9 - 11 Thursday F, S 5:00 – 5:50 ______ 12+ Thursday F, S 6:00 – 6:50 Friendship Club Age Group Day of Week Sessions Time Program* ______ 5 - 7 Wednesday F, S 3:30 – 4:20 Friendship Club- Readiness/Language ______ 6+ Tuesday F, S 4:00 – 4:50 Friendship Club- Communication -GST ______ 9 - 12 Tuesday F, S 6:00 – 6:50 Friendship Club- Interactive Language ______ 12 - 16 Wednesday F, S 5:30 – 6:20 Friendship Club- Interactive Language -GST *If your child was referred by Kaiser, you must attend a GST designated groups. If your child was not referred by Kaiser, you can attend a GST designated group.

12/08/15 rvsd; 06/25/16 rvsd; 12/2/2016 rvsd; 07/03/2017 rvsd

GENERAL INFORMATION There are no refunds or credits for missed classes. If a group therapist cancels a group due to illness, the group will be rescheduled at a time that is convenient for all parties. If a group therapist determines a program to be inappropriate for a child, parents will be notified and a refund will be given for remaining classes OR options to participate in a more appropriate program will be discussed with parents. Initial here that you understand missed classes policy ________

DATES OF GROUPS

Spring Groups begin the week of January 14, 2018

TUITION* Fall & Spring Sessions New Student $71/ week or $994 (14-sessions) Continuing Student $61/ week or $854 (14-sessions) New Student Initial Consult Fee $100 Tutoring: $70 per session Q &A with Dr. J Offered once per month for $40- sign ups in office Speech therapy: $100 per session *Upon request, tuition can be divided into as many as four equal payments with all checks or credit card information submitted at time of enrollment. The first check must be dated on the first date of class and the final check post-dated no later than week #11. LOCATION OF PROGRAMS Centerpointe Building at 18 Crow Canyon Court, Suite 225, San Ramon, CA 94583 REGISTRATION PROCEDURES Upon receipt of your registration form and full tuition via credit card or check (post-dated checks accepted), your child's name will be added to the class list. Once a minimum of 3 children has signed up for an individual program, a confirmation email will be sent to you about 10 days before group sessions begin. If your child is NEW to our program, you must contact Ms. Aly via email aly.healthyminds@gmail.com or phone 925 484 0074 to arrange for a consultation with Dr. J. Refunds are available if cancellation is received 10 days prior to beginning of Session minus a $35 Service Fee. Failure to cancel will result in a $50 service fee and a $35 Service Fee is for returned checks. Tuition must be received prior to or on the first day of the Fall or Winter Session. Children will not be able to participate in the program until fees have been received or fee arrangements have been made with Dr. Johnstone.

Mail Registration & Full Tuition to: Dr. Theresa Johnstone c/o Healthy Minds Healthy Body Institute

18 Crow Canyon Court, Suite 225 (Credit Card Information) San Ramon, CA 94583 Name as appears on Credit Card:____________________________ Card Number: ________ _______ _______ ________ Expiration Date: CVV #: Zip Code: Please call Dr. Theresa Johnstone or Ms. Aly @ 925-484-0074 with questions.